Provider Demographics
NPI:1659564052
Name:NABIZADEH, BENNY
Entity Type:Individual
Prefix:
First Name:BENNY
Middle Name:
Last Name:NABIZADEH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1850 VETERAN AVE APT 102
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-6347
Mailing Address - Country:US
Mailing Address - Phone:310-435-7586
Mailing Address - Fax:
Practice Address - Street 1:11607 W WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-5915
Practice Address - Country:US
Practice Address - Phone:310-927-7658
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-20
Last Update Date:2007-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56220122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist